2.28 ELEMENTOS CULTURALES

Our theory of comprehensive treatment includes different levels of intervention which are:

Level 1: prevention. Level 2: harm reduc- tion. Level 3: diagnosis and treatment of asso- ciated pathologies. Level 4: specific treatments. Level 5: rehabilitation and social integration. Level 6: prevention and treatment of relapses. These levels can be delivered individually or together in a coordinated manner, depending on the needs and willingness of the patient.

2.1 Level 1 (Prevention)

Currently an efficacious primary preven- tion model does not exist. Educational models based on particular cultural backgrounds are rarely acceptable to all.

Although drug dependence may have its roots in societal organization, or in consumer- ism, educational models alone are not effective preventive measures and may cause diametri- cally opposite results in social groups with dif- ferent cultural backgrounds. Research has not discovered specific educational impairments nor temperamental types associated with drug addiction. A large number of subjects begin using drugs recreationally or to facilitate so- cialization without knowledge of the real risks

and consequences of drug abuse.

As a primary prevention model, we sug- gest a public health education program on the various psychoactive substances of abuse, ef- fects, consequences of use and abuse, devoid of ideological and moralistic interpretations which often succeed in leaving a mythical and mysterious imagine which fascinates [36, 37].

If health education constitutes a valid pri- mary prevention policy, secondary prevention (harm reduction, therapy, prevention and treat- ment of relapses) must not be overlooked.

Research indicates that the spread of heroin use correlates to precise market interests which are kept alive in certain well-defined condi- tions such as clandestineness which implies high cost, consumer-pusher phenomena and when effective therapy is lacking. Within this framework depenalizing drug use and treat- ing drug addicts are essential cornerstones in the elimination of this problem [27].

2.2 Level 2 (Harm Reduction)

The aims of level 2 may be summarized as follows:

• reduce the social consequences related to addiction, such as: criminal activity, spread of AIDS, extinction of the con- sumer-pusher phenomena, elimination of the clandestine market with subsequent reduction of number of heroin users, and minor risks for the general population. • protect heroin addicts from syringe relat-

ed pathologies (HIV, hepatitis, vascular damage, endocarditis, overdose, with- drawal syndrome, etc.); this will prove advantageous for the patient and will re- duce social costs.

• more accessible public health services for the heroin addict population [28-31]. Es- tablishing the first contact between medi- cal staff and addicts means (1) reaching a larger number of subjects; (2) offering accurate information regarding physical and mental well-being and therapeutic prospects [16].

• the possibility of an early diagnosis which

is presently impossible since drug addicts live in clandestineness. The patient usu- ally seeks help when the situation is no longer bearable and course progression is well advanced.

Proposable interventions at level 1 include: • expansion of agonist opioid therapy pro- grams such as methadone or other opioid therapies (LAAM, Buprenorphine). The Swiss experiments with heroin didn’t support conclusive evidence [12]. They had not good control group and the her- oin patients received much more psycho- social treatment than the methadone pa- tients. Also, the heroin clinics were much more expensive to run than methadone programs and is unclear where heroin clinics fit into the overall framework of treatment programs .

• free distribution of disposable syringes • instructions regarding self-administra-

tion of medications.

• information regarding first aid in case of overdose or withdrawal syndrome • information regarding the risks and con-

sequences of continued use of illicit drugs and modalities of treatment and rehabili- tation.

• health education of HIV subjects

The operative phase of level 1 would be car- ried out by volunteers and specialized work- ers in "street units". Family physicians as well as ambulance paramedical personnel should also be involved. In this way a tight network of contacts between health services and drug addicts is assured and access to health services is facilitated.

The effectiveness of a pragmatic approach is widely demonstrated in the experience of countries such as England and Holland which have succeeded in limiting the spread of her- oin addiction (e.g. in 1991 in the United King- dom 8,000 heroin addicts were officially regis- tered; there were no deaths due to overdose, the spread of AIDS was limited and restricted to subjects at risk, prevalently homosexuals. In Italy with its moralistic and repressive atti- tude, in the same period there were more than 320,000 heroin addicts, 1,200 deaths by over- dose, widespread diffusion of HIV and 70% of

heroin addicts were seropositive).

The drawback of this first level is that it is not an actual treatment modality and therefore it cannot help patients recuperate bio-psycho- social functioning [16]. In order to achieve this goal we must pass to the next level of our pro- gram which includes services and more quali- fied personnel.

2.3 Level 3 (Diagnosis and treatment of as-

sociated pathologies).

At this level the specific treatment of drug addiction begins. The patient is examined by a medical specialist and other professional per- sonnel in order to arrive at a diagnosis and es- tablish a therapeutic plan appropriate for that subject. Scientific literature is in agreement in defining heroin addiction as an illness and ex- perience shows that it is the patient's degree of impairment together with other factors that determine if a particular intervention is suit- able or unsuitable at that time [32, 38]. The principal task of the specialized staff at this stage is to formulate a diagnosis. and identify potential resources (personal attributes, family members or social skills), that may help in re- habilitating the patient. This will be possible if interviewing techniques reactivate a two way communication in order to identify the needs of the patient and offer concrete proposals. Particular attention should be given to unsuc- cessful endeavors which are often indicative of errors in the interventions proposed or in monitoring of the patient.

This level requires more qualified personnel and specialized services. Specialized centers for the diagnosis and treatment of addiction are needed. These centers should be equipped to carry out research, collaborating with Ph. D. Research Programs in Drug Addiction, and educate and train specialized personnel.

Once a diagnosis has been made, the pa- tient undergoes the appropriate therapeutic modality. The initial choices, however, should not be restrictive or rigid but rather open and interchangeable with other modalities. Only if the patient acquires and maintains a func-

tional state will the staff be able to verify the choices made.

At the same time associated pathologies and psychiatric disorders are diagnosed and treated [1, 15, 20, 26, 35].

2.4. Level 4 (Specific treatments).

This level includes therapeutic and rehabil- itate interventions after the patient has under- gone clinical assessment. Generally patients may be divided into two groups:

• patients who do not require opioid ago- nists.

• patients who require opioid agonist long term therapy (Methadone/Buprenor- phine Maintenance; LAAM Maintenance; Buprenorphine-Naloxone Maintenance).

2.4.1 Patients who do not require opioid agonists.

The patients included in the first group should satisfy the following requisites: they are subjects who meet DSM-IV or ICD-10 cri- teria for a substance use disorder; they have no psychiatric comorbidity [18]; low craving; good social adjustment; good family support with the possibility of a referring family mem- ber; these subjects are reliable and have good interpersonal relationships with staff [11, 14, 25].

It is important to underline that methods based on a “drug free state” are highly selec- tive and applicable to a very small number of patients [23]; however some antisocial and very resistant addicts do very well in these programs and do not respond to anything else. It is understandable then, the caution needed before detoxifying patients, as well as, the need to control attentively behavior at risk and immediately admit the patient to an ago- nist treatment program if difficulties arise.

Methods for achieving a drug free state may be outlined as follows:

• Abstinence is controlled by psychothera- peutic support, with or without opioid antagonists.

reintegration during treatment. Antago- nists may also be used in this case. • We suggest Therapeutic Community’s

(TC) with more flexibility and research to determine who fits best into the rigorous ones that currently dominate the scene. NIDA is supporting studies of more “flexible” TC’s (those that use medica- tions and treat dual diagnosis patients).

2.4.2 Patients who require opioid agonist long term

therapy.

This group includes the large majority of drug addicts who seek help. They do not meet requisites for “drug free” programs which would be detrimental for these subjects.

The first task the staff must face is that of redefining the patient’s expectations suggest- ing long term treatment which will probably be more successful and safer.

One should aim to set up services that are able to support and be integrated with a long term agonist therapy

• Basic counseling. Many patients on meth- adone or on other substitutive therapies who have obtained metabolic stabiliza- tion experience a return to normality; they become socially reintegreted espe- cially if they have personal resources, help from family members (home, work, hobbies, etc). For these patients therapeu- tic success may be possible with specific information and treatment counseling. • Treatment of psychiatric disorders with

psychotherapy and/or pharmacotherapy along with drug counseling for patients with psychiatric disorders

• Self-help groups could provide solid support to those subjects who lack reha- bilitative resources. In future we suggest that more attention be focused on these groups because they are at low cost, have been shown to be effective in other areas (alcohol, psychiatric pathologies, etc) and more subjects can be treated simultane- ously.

• Residential communities. These commu- nities would serve those subjects who need specialized social structures in ad-

dition to pharmacotherapy. They are drug addicts with serious psychiatric dis- orders as well as those addicts who find themselves jobless and homeless.

• In closing we would like to underline: • The therapeutic communities would be

linked to social agencies and other health services. They would no longer be re- clusive structures and isolate the patient from his family and social ties. They must not create an artificial world in which re- covery is obtained and quickly lost when the patient is released. Contrary to what happens in Italy, in the US, many TC’s work very hard to integrate patients back into the real world prior to discharge. It is important to have a transition phase so as to help the patient overcome the prob- lems associated with the artificial envi- ronment.

• The primacy of "drug free" programs should be abolished. Recovery cannot be associated with a "drug free" state. It should be related to the psychological and social functioning.

2.5. Level 5 (Rehabilitation and social inte-

gration).

This level foresees the complete rehabili- tation of drug addicts independently of the kinds of treatment modalities in progress. The achievement of this goal varies (length of time and modality) according to the needs and the severity of illness of each individual. The interventions which allow the patient to achieve this status vary, for example: getting a job, reintegration into family life; methadone, LAAM, buprenorphine detoxification.

We would like to focus the need of those patients who cannot be deprived of agonist therapy due to biological determinants. A sub- stantial part of the drug addict population who have good social and psychological adjustment require agonist therapy but not social support services. We consider these patients completely recuperated and feel that they are able to man- age their pharmacotherapy i.e. as diabetics do.

For these subjects agonists availability should be convenient and interfere as little as possible with the patient's life, work and leisure time The patient could be entrusted with dosages that cover a longer period of time; family doc- tors would be able to prescribe methadone or other substitutive therapies. Any community health service could dispense of methadone or of other substitutive therapies under certi- fication in order to facilitate the patient. On in- ternational level contacts could be established between the health services of different coun- tries permitting the patient to travel freely. The organization of a heath service network would prove advantageous for the patient who need not travel great distances to reach specialized centers and at the same time these centers would not be overloaded with work-dispens- ing of methadone or of other substitutive ther- apies to patients who are rehabilitated, thus reducing social costs.

2.6. Level 6 (Prevention and treatment of

relapses).

Given the definition of heroin dependence as a chronic and relapsing illness, it is logical to emphasize the role of prevention and ther- apy of relapses. This requires therapeutic mo- dalities which help in conserving the skills and functioning level previously achieved by the patient. Thus patients would be rapidly read- mitted to methadone or to other substitutive therapies (it is obligatory with recurrences) in order to prevent harm to the patient i.e. return- ing to street life. Treatment would be simpli- fied in these programs as these patients have been rehabilitated in the past. In order to ac- celerate readmission to any health service the patient would be provided with documenta- tion containing clinical chart data.